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Viagra Use in a Community-Recruited Sample of Men Who Have Sex With Men, San Francisco
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AIDS Journal of Acquired Immune Deficiency Syndromes June 2003; 33(2):191-193
Priscilla Lee Chu; *Willi McFarland; Steven Gibson; Darlene Weide; Jeff Henne; Paul Miller; Teddy Partridge; *Sandra Schwarcz. San Francisco Department of Public Health, San Francisco; Stop AIDS Project, San Francisco; and The Henne Group, San Francisco, California, U.S.A.
San Francisco and several other cities in North America and Europe have observed increases in unprotected anal intercourse, sexually transmitted diseases (STDs), and HIV incidence among men who have sex with men (MSM) in the last few years. Viagra (sildenafil citrate), a drug used to treat erectile dysfunction, became available near the beginning of these trends. Two previous studies in San Francisco documented that Viagra use was associated with high-risk sexual behavior among MSM. The first study, a survey of circuit party attendees, noted high levels of Viagra use in combination with illicit drugs. Fourteen percent of those who attended distant circuit parties had used
Viagra within a 72-hour period. Survey participants who had used Viagra reported an almost fourfold increase in unprotected anal sex with a partner of unknown or opposite HIV serostatus compared with those who did not take
Viagra. Being HIV-positive, speed ("meth" or "crystal") use, and popper (amyl nitrate) use were also significant factors in high-risk sexual behavior. The circuit party study raised the additional concern of drug interactions with Viagra, particularly with poppers, which can cause a life-threatening drop in blood pressure. In the second study, conducted at San Francisco's municipal STD clinic, 32% of MSM who sought STD treatment between December 2000 and February 2001 reported using Viagra. Viagra users reported significantly more sex partners and were more likely to have an STD diagnosis.
The two studies, however, are limited in generalizability due to the selected study populations of circuit party and STD clinic attendees. We therefore took the opportunity to survey a broader sample of MSM through the course of HIV
prevention outreach activities conducted by a local community-based organization, the STOP AIDS Project. The objectives of the survey were to gauge the magnitude of Viagra use among MSM in San Francisco, its association with high-risk sexual behavior, and its use in combination with other drugs.
The authors conducted a community-based anonymous survey of 837 men who have sex with men (MSM) to gauge the extent of Viagra (sildenafil citrate) use, its association with high-risk sexual behavior, and its combination with other
drugs. Participants' mean age was 35 years, 67% were white, and 66% had a college degree. The majority (76%) reported anal sex in the past 6 months, with 49% reporting always using condoms. Overall, 32% had ever used Viagra
(CI: 29%-36%). Significant independent predictors of Viagra use were white race, older age, HIV positivity, illicit drug use, and having had unprotected anal sex with potentially serodiscordant partners. Over one third of Viagra users had
combined Viagra with other drugs, 18% with amyl nitrate. Only a minority (44%) obtained Viagra under the care of a physician. For some MSM, Viagra appears to be an emerging contributing factor to unsafe sex, potentially increasing HIV transmission. HIV care and prevention providers should target Viagra users for enhanced education on safer sex and potentially harmful drug interactions.
More than one fifth had used Viagra within the past 6 months. Recent use
was even higher (42%) among HIV-positive MSM. Recent Viagra use was nearly twice as common among men who reported unprotected anal sex with someone whose HIV serostatus was unknown to them.Viagra was commonly combined with other drugs. Overall, 36% of all Viagra users had combined use with other drugs, including speed (23%), ecstasy (18%), ketamine (K, 11%), and gamma-hydroxybutyrate (GHB, 8%). Of particular concern, 18% reported combining Viagra with poppers. Among persons treated for HIV, 11% had combined Viagra with antiretroviral medication (referred to as highly active antiretroviral treatment [HAART]). Although the particular antiretroviral medication was not recorded, ritonavir has been shown to increase the level of Viagra several-fold. The majority (56%) of Viagra users did not obtain Viagra from a physician; 44% obtained Viagra from a friend, 6% on the Internet, 4% on "the street," and 10% from "other sources."
We recognize this study had limitations. Although the survey included a large number of MSM recruited at diverse venues, respondents were a convenience sample. We do not know how many men declined to be surveyed and how
they differed from respondents. Answers were self-reported, potentially leading to underreporting of stigmatized behaviors, including Viagra use, illicit drug use, and unprotected serodiscordant anal intercourse. Because questionnaire space was limited, we did not quantify how often Viagra was used; we only ascertained having ever used Viagra and having used Viagra in the past 6 months. Another limitation is the inability to demonstrate a causal relationship between Viagra use and increased risk of HIV transmission in a cross-sectional survey.
Despite these limitations, our survey corroborates two other studies in San Francisco finding that Viagra was associated with unprotected anal intercourse, potentially with HIV serodiscordant partners. Viagra can treat physically,
psychologically, or pharmacologically induced erectile dysfunction, establishing the biologic plausibility that Viagra can enable unsafe sex that otherwise may not have occurred. Situations where Viagra is combined with speed or other drugs present such a scenario. A study among gay men in London did not find a causal association between Viagra use and unprotected anal intercourse while taking Viagra, but there was a positive association between Viagra use and use of recreational drugs.
The strength and consistency of findings suggest that Viagra may be a new contributing factor for unsafe sex with the potential for increasing HIV transmission for some MSM. Our study also points to prevention opportunities. Physicians prescribing Viagra are presented with an ideal moment to discuss not only potential drug interactions but sexual risk for HIV and STD with their patients. Community-based prevention providers are needed to develop campaigns and ensure that the same health education messages reach those who do not obtain Viagra from their physicians.
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